Exploring Influences on COVID-19 Messaging on Behavior in Virginia

A mixed-methods study conducted by Cook and colleagues sought to understand how health behaviors might influence COVID-19 infection rates in Virginia early during the pandemic. The study was advertised on social media and online, and data were collected online. Thirty-one percent of participants (n = 1041) lived in an Appalachian county. A high proportion reported changing their behaviors to be safer; for example, 95% said they practiced social distancing and 89% said they washed their hands more often. However, 121 participants (12% of the sample) reported that they believed one or more false or inaccurate messages, most commonly that COVID-19 was developed as a bioweapon. These participants were more likely to self-identify as Republican, be 18–24 years old, and have a high school diploma/GED or below. The investigators subsequently convened several virtual focus groups with community subgroups including African Americans and young adults. Themes that emerged included confusing or contradictory advice about COVID-19 risk and transmission and “pandemic fatigue.”

Social Determinants of Health: Families, Youth, and Race

Ballard and colleagues described preliminary findings from a pilot study examining social and health needs and assets among primarily African American women transitioning to adulthood (ages 18–29). The team conducted 15 semi-structured in-person interviews of African American women residents of Northeast Winston-Salem, a structurally disadvantaged urban area within Appalachia. Themes that emerged included the following: wellness defined holistically to encompass both mental and physical health; mental health identified as a more salient topic than physical health; of their most prominent concerns and structural barriers to health and wellness that included inadequate medical insurance and reduced access to care. In this study, the transition to adulthood emerged as an under-recognized developmental period for health and wellness, and resources were identified as less available compared to people in other life stages.

Substance Use: Collaboration, Partnership, and Prescribing

Vissman and colleagues examined referral and discharge patterns at the first public access, clinically managed withdrawal management treatment center in the Cincinnati area. Cincinnati is a national epicenter for opioid overdoses. Noting a dearth of reports on patterns of referral to and from clinically managed withdrawal management services supported by the American Society of Addiction Medicine, this team performed a retrospective chart review from May 2018–2019 of 588 unique admissions to one withdrawal management treatment center in Cincinnati. Most clients (73%) were on Medicaid, and the majority (68%) were men. Of the 109 individuals admitted, nearly all (98%) were admitted for residential services. About 40% had successful discharge referral status (confirmed housing and plans for medically assisted treatment at discharge).

Gay, bisexual, other men having sex with men (GBMSM) and transgender persons are at increased risk for HIV, sexually transmitted infections (STIs), and hepatitis C. Although some services exist, including syringe services, health disparities remain, as does a need for culturally congruent interventions for racially/ethnically diverse GBMSM and transgender persons in rural Appalachia. Rhodes and colleagues described the early phases of a novel community-based participatory research study to integrate mHealth outreach and peer navigation strategies to increase rates of testing for HIV, STIs, and hepatitis C and engagement in care; and use of related prevention and care services, including syringe services. In this ongoing NIH-funded project, community health leaders and their social network members are being randomized to mHealth social media/peer navigation intervention arm or a delayed intervention arm.

Food Insecurity and Health: From Clinical Screening to Community Engagement

Best and colleagues described two pilot clinic-based interventions aimed to reduce food insecurity. The first program, “Food is Health,” screens all patients in an urban outpatient clinic for food insecurity with a validated 2-item screening tool [Reference Hager, Quigg and Black15]. Responses are then incorporated into the provider workflow and captured and flagged in the electronic health record (EHR) if responses indicate any possible food insecurity. For those with food insecurity, a navigator provides food for three meals for a family of four through an on-site food pantry and facilitates referrals to other food resources. Preliminary data suggest that over two years, the program has significantly reduced food insecurity among clinic patients, with caregivers having a significantly lower odds of reporting food insecurity after the program was begun (OR = 0.56, 95%CI 0.48, 0.66; p < 0.001).

Successes in Patient Navigation and Telemedicine to Improve Health and Well-Being in Populations Living in Appalachia

Cancer patients in Appalachia are often isolated and face transportation challenges that can significantly affect prevention, diagnosis, care, and recovery. Copus and colleagues presented population health navigation as a pilot strategy to address these challenges. Three navigators were hired, trained, and supported to focus on the needs of rural African American and Latinx patients. Using EHR data of rural patients, the team identified treatment logistics and financial/insurance matters to be the primary barriers to care. Thus, nearly 65% received support for transportation and 47% for parking. Overall, 59% of patients were referred to supportive care services, including mental health counseling, financial resources, or housing support. Based on study findings, financial barriers will be assessed in future research.

Lengerich described engagement at the policy level to improve cancer care coordination in Pennsylvania. The Penn State Cancer Institute’s 28-county catchment area includes 19 Appalachian counties. Pennsylvania has a governor-appointed Cancer Advisory Board and a statewide Cancer Coalition (a workgroup with over 100 members).[Reference Nirmal, Rodriguez-Colon, Costalas and Lengerich16] Key recommendations from the workgroup to improve care coordination in complex settings included incorporating patient navigators into care pathways and classifying their services as reimbursable by insurance companies. The Coalition also called for standard criteria and training for patient navigators and more recognition of patient navigators’ value by employers.

Food Insecurity: Across Communities

Jameson and colleagues presented data regarding barriers to nutrition and the need for nutrition education in a region of Appalachia in western North Carolina. The team surveyed participants (n = 202) in waiting rooms at two free county health clinics. Participants indicated an interest in receiving health education (overall health, weight loss, diabetes, blood pressure, and heart disease) and in using mHealth, social media, and other online resources (e.g., videos) as delivery channels. Most participants expressed interest in access to local produce (86%) and recipes (71%). While many participants noted assets, such as access to Wi-Fi and food pantries, they also noted barriers, such as irregular computer access and needing guidance on healthy meals preparation. Lack of housing or relevant resources (e.g., appliances, money, or food) were cited by 23% and 38% of clients at each clinic, respectively.

Innovative Methods to Translational Research

Radon, a naturally occurring radioactive gas, is the second-leading cause of lung cancer, and the risk of lung cancer is higher among those exposed to both radon and tobacco smoke. Despite the known risk, few people assess their homes for radon. Stanifer and colleagues described efforts to increase radon detection in Kentucky harnessing “citizen scientists.” Trained community members measured radon daily in their homes, using low-cost digital radon detectors, and texting results to investigators. Because of the pandemic, participants were recruited via social media, gave informed consent virtually using REDCap, and were trained remotely via videoconferencing. Among four counties with higher radon potential, the team has tested about 10% of homes. Affordable radon mitigation is the next step in this ongoing project.

CTSA hubs across Appalachian are collaborating to share COVID-19-related data to develop models better reflecting the region’s characteristics. For example, Gurcan and colleagues are determining social and emotional predictors of social distancing behaviors; identifying possible periods of higher parental stress using family demographics and related child welfare indicators; and assessing sleep habits and mental health factors before, during, and after “waves” of social distancing. These data will be used to design interventions to promote greater adherence to social distancing, improve coping skills (e.g., receiving SARS-CoV-2 vaccination), and reduce individual and family stress for future waves of COVID-19 infections. In addition, these data could help to reduce COVID-19 spread and mortality in Appalachia; improve access to limited resources (e.g., personal protective equipment and telemedicine); and enhance effectiveness of communications regarding future outbreaks.